2024 CAA Health Care Spending Data Collection for Reporting

In compliance with Section 204 of the Federal Consolidated Appropriations Act of 2021, health plans are required to submit information to the federal government regarding the average monthly premiums paid by employers on behalf of enrollees as well as average contributions paid by the enrollees each year. Please provide the data on this form to Western Health Advantage (WHA) to report this information.

Deadline to complete and submit this attestation to WHA is April 15, 2025.

If you have any questions on how to complete this form, please contact WHA’s Account Services team at 888.499.3198.

Section A - Group Information

Legal Company Name

DBA (Account Name)

WHA Group Number (six digits, no sub group information necessary)

Name of Person Completing Form (First Last)

Title of Person Completing Form

Role at the Group of Person Completing Form

Employer ContactBroker/Agent

Email Address

Phone Number

Section B - Contribution Information

Information requested below is based on the calendar year of 2024 for all employees, regardless of contribution type.

Note: Aggregate payroll records may be the most convenient source of this information.

Average monthly premium that is paid by the employer/group (employer contribution)

Average monthly premium that is paid by the employee/member (employee contribution)

Section C - Large Group (101 or more eligible employees) RxDC Collection

Large group employers are also required to submit information related to Form 5500. Please provide the information from your Form 5500 below.

Employer Form 5500 Plan Name

Employer Form 5500 Plan Number (3 digit code)

Contact Information